M5MEQs2016Session3:Lethargy18/11/16http://tinyurl.com/zevjhqu

Mdm Tanisa78yearoldfemale.Shepresentstotheemergencydepartmentwithlethargy.Shecomplainsofabdominalpaininthepara-umbicial region.Shehasbeenpassinghardstoolswithdecreasingamounts.Herdaughternotedthatshewasdrinkingmorewaterthanusualandgoingtothetoiletmoreoften.

Herpastmedicalhistoryincludeddiabetesmellitusforwhichsheisonglipizide15mgBD,metformin850mgTDS,hypertensionforwhichsheisonhydrochlorothiazide12.5mgOM.

Question1

Onexamination:T36BP170/72HR100SpO298%onRAGCS15,orientatedtotime,placeandpersonHS1S2LClearASoftnon-tenderslightlydistendedbowelsoundssluggishCulves SuppleClinicallydehydrated

Whichofthefollowingstatementsislikelyincorrect.1.Diabeticketoacidosisisadifferentialinthispatient2.ACTabdomenandpelvisshouldbeconsideredasaupfrontinvestigation3.Patient’sGCSshouldbecloselymonitored4.TheECGmayshowashortenQTinterval5.Hydrochlorothiazidemayhaveworsenedthepatientsunderlyingcondition

Question1

Whichofthefollowingstatementsislikelyincorrect.1.Diabeticketoacidosisisadifferentialinthispatient2.ACTabdomenandpelvisshouldbeconsideredasaupfrontinvestigation3.Patient’sGCSshouldbecloselymonitored4.TheECGmayshowashortenQTinterval5.Hydrochlorothiazidemayhaveworsenedthepatientsunderlyingcondition

Question1

Initialinvestigationsarethefollowing:Hb 8.2Tw2.3Plt 120U12Na127K3.6Bicarb 18Glu 11Cr180Alb 20AST30ALT40TB3Ca 2.6Mg0.9PO40.5

CXR:Noconsolidation,noairunderthediaphragmAXR:prominentbowelloops

Question2

Whatisthecorrectedcalciumforthispatient?1. 2.1mmol/L2. 2.8mmol/L3. 3.0mmol/L4. 3.2mmol/L5. 4.6mmol/L

Question2

Whatisthecorrectedcalciumforthispatient?1. 2.1mmol/L2. 2.8mmol/L3. 3.0mmol/L4. 3.2mmol/L5. 4.6mmol/L

Question2

CorrectedCalcium=Measuredcalcium+(40– Alb)*0.02

OrForeverydropof4g/lAlb =>CorrectCa by

0.1mmol/L• Approximately50%oftotalcalciumisproteinbound,andthetotalcalciumlevelwillvarywithprotein-bindingcapacity.• Standardlabtestsaremeasuringthetotalcalcium

Question2

Younotethepatienthasacorrectedcalciumof3.0g/L.Indicativeofhypercalcemia.Yourregistrarmakesthepassingstatementthatthepatientssymptomscanbeaccountedforduetothehypercalcemia andtheteamwouldneedtomonitorthepatientfortheclinicalmanifestationsandcomplicationsofhypercalcemia.

Question3

Whichoftheofthefollowingstatementsisfalse.1.OneofthecardiaceffectsisalongQTC2.Nephrogenic diabetesinsipidus resultinginpolydipsiaandpolyuriaisaconsequence3.Hypertensionmaybecausedbyrenalinsufficiency,calcium-mediatedvasoconstriction4.Chronichypercalcemic nephropathymaycontinuetoworsenaftercorrectionofhypercalcemia5.Pepticulcerdiseaseandpancreatitisarepossiblegastro-intestinalcomplication

Question3

Whichoftheofthefollowingstatementsisfalse.1.OneofthecardiaceffectsisalongQTC2.Nephrogenic diabetesinsipidus resultinginpolydipsiaandpolyuriaisaconsequence3.Hypertensionmaybecausedbyrenalinsufficiency,calcium-mediatedvasoconstriction4.Chronichypercalcemic nephropathymaycontinuetoworsenaftercorrectionofhypercalcemia5.Pepticulcerdiseaseandpancreatitisarepossiblegastro-intestinalcomplication

Question3

Question3

ClinicalSymptomsandcomplications:• Stones(Renalcolicandhypercalcaemicstones)• Bones(Increasedosteolysisandfractures)• Psychicmoans(Depression,confusion,hallucinationsandcoma)• Abdominalgroans(Anorexia,N,V,constipation,PUD,pancreatitis)• Other

• Muscleweakness,malaise,hyporeflexia• Confusion,apathy,decreasedmemory• Nephrogenicdiabetesinsipidus (Polyuriaandpolydipsia)

Question3

Thepatientisadmittedtothewardwiththediagnosisofhypercalcemia andanemiaforinvestigation.IVfluidswasstartedforthepatient.

Whatadditionalmanagementshouldbedone.1.Urgentchemotherapy2.Highcutoffhemodialysis3.Stophydrochlorothiazide4.Denosumab5.Bloodtransfusion

Question4

Thepatientisadmittedtothewardwiththediagnosisofhypercalcemia andanemiaforinvestigation.IVfluidswasstartedforthepatient

Whatadditionalmanagementshouldbedone.1.Urgentchemotherapy2.Highcutoffhemodialysis3.Stophydrochlorothiazide4.Denosumab5.Bloodtransfusion

Question4

Managementofhypercalcemia:Keytotreatmentisvolumeexpansion

• Promoteurinaryexcretion(ifCVSandrenalfunctionadequate)• ForcedsalineDiuresis(plusmagnesiumandpotassium)– 300-500mlNsaline/hr

• Thisreplaceslostfluidandforcesdiuresis• MustmonitororreplaceKandMgasthesewillbelostintheurinealongwiththecalcium

• NOTEdonotgiveTHIAZIDES,theywillworsencondition• TreatmentwithFRUSEMIDEiscontroversialasitpromotesCalciumbonereuptake

Question4

• Haemodialysis• TreatmentofchoiceinCVSorrenalcompromise

• Calcitonin/EDTAbisphosphonates• Reduceboneresorption andreduceGITabsorptionofCalcium• Effectin48hoursandlast15days

Question4

Furtherhistoryrevealsthatthepatienthasbeenhavingjointpainsforthelastfewmonths.Shehasalsobeenhavinglossofweightandlossofappetite.Shealsorevealsexertiondyspneaandnon-vertiginousgiddiness.Hb 8.2Tw2.3Plt 120U12Na127K3.6Bicarb 18Glu 11Cr180Alb 20AST30ALT40TB3Ca 2.6Mg0.9PO40.5

CXR:Noconsolidation,noairunderthediaphragmAXR:prominentbowelloops

Question5

Whatadditionalinvestigationswouldyouorder?- OGDandColonoscopy- SkeletalSurvey- Bonemarrowaspirate- Myelomapanelandlightchains- CTabdomenandpelvis- Waterdeprivationtest- Arterialbloodgas- Ironstudies

Question5

Whatadditionalinvestigationswouldyouorder?- OGDandColonoscopy- SkeletalSurvey- Bonemarrowaspirate- Myelomapanelandlightchains- CTabdomenandpelvis- Waterdeprivationtest- Arterialbloodgas- Ironstudies

Question5

Multiplemyeloma(MM)ischaracterizedbytheneoplasticproliferationofasinglecloneofplasmacellsproducingamonoclonalimmunoglobulin.

Diagnosis:Clonalbonemarrowplasmacells≥10%orbiopsy-provenbonyorextramedullary plasmacytoma andanyoneormoreofthefollowingCRABfeaturesandmyeloma-definingevents

Question5

• (C)Hypercalcemia:>2.75mmol/L(>11mg/dL)• ( R)Renalinsufficiency:creatinine clearance<40mL/minc perminuteorserumcreatinine >177µmol/L(>2mg/dL)• (A)Anemia:Hb <10g/dL• ( B)Bonelesions:oneormoreosteolytic lesiononskeletalradiography,CT,orPET/CT. Ifbonemarrowhas<10%clonalplasmacells,morethanonebonelesionisrequiredtodistinguishfromsolitaryplasmacytoma withminimalmarrowinvolvement

Question5

Haematologywasreferredandpatientwasofferedabonemarrowtoconfirmthediagnosisofmultiplemyeloma.Youarecalledtotaketheconsentforthispatient.

Whichofthefollowingstatementspertainingtoinformedconsentistrue?1.Theconsentshouldbetakenbythepersondoingtheprocedure2.Apersonwithahistoryofschizophreniacangiveinformedconsent3.Apersonwithahistoryofdementiacannotgiveinformedconsent4.Aconsentisvalidaslongasthepatienthassignedontheappropriateforms5.Achildbelowtheageof16cannotgiveavalidconsent.

Question6

Haematologywasreferredandpatientwasofferedabonemarrowtoconfirmthediagnosisofmultiplemyeloma.Youarecalledtotaketheconsentforthispatient.

Whichofthefollowingstatementspertainingtoinformedconsentistrue?1.Theconsentshouldbetakenbythepersondoingtheprocedure2.Apersonwithahistoryofschizophrenia cangiveinformedconsent3.Apersonwithahistoryofdementiacannotgiveinformedconsent4.Aconsentisvalidaslongasthepatienthassignedontheappropriateforms5.Achildbelowtheageof16cannotgiveavalidconsent.

Question6

Principlesofavalidconsent:- Thepersongivingconsentmustbecompetent- Consentmustbevoluntaryandnotsubjecttoduress orcoercion- Thepersonmusthavebeengivensufficientinformationtoreachadecision

- Thetreatmentmustnotbeunlawfuloragainstpublicpolicy.

Othernotes:• Childrenyoungerthan16mayconsentiftheyareGillick competent=>sufficientmaturityandunderstandingtomakethenecessarydecision.

Question6

• ClinicalpresentationofHypercalcemia• ApproachtotheworkupofHypercalcemia• Complicationsofhypercalcemia• Causesofhypercalcemia

LearningPoints